Annals of Internal Medicine tip sheet for Dec. 4, 2012

1. American College of Physicians Says Upper Endoscopy Overused in Patients with Reflux

Routine use of upper endoscopy for most patients with gastroesophageal reflux disease (GERD) does not improve patient health, is associated with preventable harms, and may lead to unnecessary interventions and costs, says the American College of Physicians (ACP) Clinical Guidelines Committee in a new evidence-based clinical policy paper. Heartburn, a symptom of GERD, is a common reason for people to see a doctor. Long term complications of GERD can include scarring of the esophagus (strictures) and esophagus cancer. A small number of people with GERD develop an abnormal lining to the esophagus (called Barrett's) and a higher risk for esophagus cancer. Some doctors routinely use endoscopy to diagnose GERD and then to screen people with GERD for Barrett's and cancer. However, the benefits of using endoscopy this way are uncertain. After reviewing available evidence, the ACP advises that upper endoscopy should not be routinely performed in women of any age or in men under the age of 50 with GERD symptoms because the incidence of cancer is very low in these populations. Upper endoscopy is indicated in patients with GERD symptoms who are unresponsive to medicine to reduce gastric acid production for a period of four to eight weeks or who have a history of narrowing or tightening of the esophagus with recurrent difficult or painful swallowing. Screening with upper endoscopy may be indicated in men over 50 with multiple risk factors for Barrett's esophagus. Among patients found to have Barrett's esophagus, upper endoscopy is indicated every three to five years. Physicians should utilize education strategies to inform patients about current and effective standards of care. Medicine to reduce gastric acid production is warranted in most patients with typical GERD symptoms such as heartburn or regurgitation.

John I. Allen, MD, MBA, AGAF, vice president of the American Gastroenterological Association, authored an accompanying editorial. According to Dr. Allen, the overuse of endoscopy highlights a significant problem in our health care delivery system where "volume drives payment, reimbursements occur in independent silos, decisions are often made without informed patient input, and health outcomes are dissociated economically from specific services rendered." To be good stewards of our health care resources, Dr. Allen says, physicians must work to avoid low-value care.

Note: For a PDF, please contact Megan Hanks or Angela Collom. To speak with an ACP spokesperson, please contact Steve Majewski at smajewski@acponline.org or 215-351-2514. To speak with the editorial author, please contact Dr. John Allen directly at JAllen@mngastro.com.

Interactive computer alerts to warn health care providers of virologic failure improve patient outcomes in HIV. Health care information technology can be used to improve quality and safety of health care, yet such clinical decision-support systems (CDSS) are lacking in HIV care. Researchers designed a randomized, controlled trial to test the efficacy of a CDSS that generates alerts to notify HIV out-patient care providers of adverse events or missed appointments through the provider's electronic medical record (EMR) home page, patient-specific EMR page, and bi-weekly emails. The alerts provided key clinical information and provided a mechanism for providers to request appointments and/or lab work. Thirty-three HIV care providers followed 1,011 patients with HIV for one year. Patients were randomly assigned to receive either "static" alerts or alerts from the CDSS. Patients in the CDSS group had a clinically significantly greater increase in mean CD4 cell count compared with the static alert group. The CDSS improved provider follow-up practices and satisfaction with the interactive alert system was high.

Note: For a PDF, please contact Megan Hanks or Angela Collom. To speak with the author, please contact Sue McGreevey at smcgreevey@partners.org or 617-724-2764.

Tracking volume-doubling time (VDT) could help to distinguish aggressive tumors from nonaggressive tumors, alleviating some of the overdiagnosis concerns related to lung cancer screening, such as overtreatment leading to unnecessary morbidity, stress, and cost. Researchers used VDT to track tumor growth in 175 high-risk patients diagnosed with primary lung cancer using low-dose computed tomography (LDCT). The researchers found that most cases (75 percent) of cancer were fast-growing. These findings suggest that a reasonable threshold to separate aggressive from nonaggressive lesions is a VDT of 200 days. In even fast-growing cancer, early treatment resulted in good long-term survival. However, overtreatment is a possibility, as 29 of the 175 patients diagnosed with cancer underwent surgical biopsy for benign disease. The researchers suggest further studies to assess whether VDT can help reduce overdiagnosis in lung cancer screening programs.

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